Good Hope, Heartlands, and Solihull Eye Clinics

Allergic Conjunctivitis

David Kinshuck


 

Introduction: allergic ocular surface disease

There are several types of allergic eye disease:

Causes

the symptoms

Examination

Allergic conjunctivitis, including children:

Allergic conjunctivitis is a common condition. The eyes become red and very itchy, and generally the sight is good. There may be a runny nose and sufferers may feel unwell. The allergy usually gets better itself, but the condition then returns every now and again. 'Itchy red eyes' occurring now and again, particularly if you suffer from hey fever or other allergies, is the main symptom.

Many people with allergic eye disease also have dry eyes and blepharitis, which may also be helped with treatment. 'Dry eyes' feel as though they are burning; eyes with blepharitis feel irritable and gritty.

If the allergy occurs during the hay fever season, then it is related to hay fever, and termed 'seasonal allergic conjunctivitis'. But if it occurs all the year round you are probably allergic to dust, and termed 'perennial'.
Alternatively you may be allergic to cat fur, for instance. 

Pollution in the air increases allergy rates considerably. Some people are allergic to contact lens solutions. 

 

Medical treatment

This page outlines different treatments. If the condition is severe, advice from an ophthalmologist is essential. Anyone with sore eyes should ideally not use more than 4 eye drops a day containing preservative; if more drops are needed, they should be preservative free.

 

Extremely mild 

Optichrom eye drops are virtually 100% safe for long term use and can be very helpful. They stop the 'allergy cells' on the surface of the eye, the mast cells, releasing chemicals that make the eyes irritable. Nedocromil  (Rapitil) and Lodoxamide are more modern and quicker acting forms of Optichrom and should tried if Optichrom has not helped enough. They are generally not helpful  for patients attending hospital clinics as their condition is more severe.

 

Preservative free lubricants

These are make the surface of the eye smooth. For mild disease Viscotears or Xailin gel 4 times a day may help. Xailin night may help at night.

Most patients attending hospital will need more intensive lubricant drops

dry eye with lubricants

enlarge

 

Moderate disease

Opatanol, Olopatadine bd (twice/day) US name is Patanol It is a mast cell stabiliser/antihistamine, and can help see   see.

 

Antihistamine tablets

Antihistamine tablets such as Cetirizine , Levocetirizine (5mg >6y age), Loratidine Others. They may make you too tired but are generally safe.
There are many types of antihistamine tablets and some make more people tired than others. Ask your doctor and pharmacist for advice. If you have many episodes of ATKC and find this helps, start these as soon as the eyes get sore.

 

Steroid drops for more severe problems

Most hospital patients will need steroid eye drops, and these should be preservative free, such as dexamethasone preservative free e.g. Dropadex. They should not be used without an ophthalmologist's advice, unless your GP is experienced in their use and you only use them for short periods.

They have side effects, such as increasing the eye pressure, (causing glaucoma) and cataracts (which may need surgery later). Even short term use of steroid drops can activate herpes simplex keratitis.

If the eyes are red and sore and itchy, start 4 times a day. As soon as the redness fades, usually about 4 days, start to reduce the dose of the steroid to 3 and then twice a day. Once the redness has faded, continue for a few more days and then try to stop them.

If the redness and itch returns every time you stop, and as advised by your ophthalmologist, you may need to use a low dose regularly, such as once a day, and later alternate day use, or every third day etc, and then stopping.

Steroid drops have many side effects if used in the wrong manner. You need to be certain that you do have 'allergic conjunctivitis' and not another condition, and most people can recognise when their eyes are red and itchy the condition has returned.

If you have a scratchy and painful eye, you may have an ulcer and the drops should be stopped and you should get expert advice.

 

Protopic/Tacrolimus ointment (and Cyclosporine)

Tacrolimus ointment 0.03 % twice day (Protopic) to skin around eye cream twice takes a few weeks to work, so it should be started whilst the patient is using the steroid drops, with a maximum effect at 6 months, although there should be a definite improvement after 4 weeks. Some of the Protopic ointment should be allowed to enter the eye (otherwise there will be no effect on the conjunctiva).

Once the Protopic is working, the dose of the steroid drops can be reduced and may be stopped or continued at a low dose (reducing from 4 times a day to once a day or less often perhaps). When the Protopic is started it stings for a few days, but the stinging effect wears off. see see  tacrolimus
Tacrolimus is more effective than Cyclosporine.


 

Treat the nose

Rhinolast and nasal spra, will help if the conditon affects the nose, and this will help the eyes. (eg hey fever).

 

Immunotherapy for hay fever
(& seasonal allergic conjunctivitis)

In many parts of the country immunotherapy is available for hay fever sufferers, but is difficult to access in Birmingham. Some people dispute the effectiveness of immunotherapy, but it is probably very helpful for some people, and slightly less helpful for others.
Your GP will need to advise you about immunotherapy in your specific case, but if your hay fever is bad the medical literature advises it should be available to you and recommends you consult an immunologist.
Homeopathic remedies help some people, but not others, and are not suitable as a replacement for immunotherapeutic advice if your symptoms are severe and you need steroid tablets.
See  www.asthma.org.uk, especially if you have asthma.

 

Summarising: stepwise treatment of allergic conjunctivitis, including children

Stepwise treatment of allergic conjunctivitis
  • Look again at prevention, especially if you are allergic to dust.
  • Anti-dust measures such as freezing bedding/pillows/pillow cases for a few hours or buying a new pillow or special covers can help.
  • Healthy diet, vegetables, fish, exercise, no smoking, vitamin D, avoiding obesity
  • vitamin D supplements
  • Nedocromil and Lodoxamide Optichrom (or Rapitil) drops (completely safe).
  • Lubricants such as Vismed, Hyloforte, Hyabak, Clinitas (sodium hyaluronate 0.4% preservative-free) evey 1/2 -2 hourly
  • Night time lubricant: best VitApos at night, Xailin night second best.   
  • Cetrizine drops in US
  • certainly seek your GPs help. 
  • Olopatadine (Opatanol) bd (twice/day) helps many people.
  • At this stage it is best to seek specialist help if you are still having severe problems,
  • Antihistamine tablets may help. You may need a slightly higher than recommended dose if your hey fever is very troublesome. Cetirizine but there are many others. Levocetirizine (5mg >6y age), Loratidine Others.
  • dexamethasone drops preservative free, and this should not be used without an ophthalmologist's advice, unless your GP is experienced in its use and you only use it for short periods, start 4 times a day for a week and reduce.
  • Severe cases, guided by an ophthalmologist. Protopic: Occ tacrolimus  0.03 % bd to skin around eye, allowing a little to enter the eye.
  • more severe caes may need immunopsupressions

Some other specific types of allergic eye diease

 

Atopic keratoconjunctivitis

Moorfields  In this condition the surface of the eye becomes red and sore and inflamed. This is a type of allergic eye disease, and is similar to vernal conjunctivitis and giant papillary conjunctivitis. The immune system becomes overactive; a type 2 hypersensitivity reaction. The cause is not known, but it is partly genetic. There are environmental factors we partly understand, and these are discussed below.

The condition affects the conjunctiva, the cornea, and the conjunctiva under the eyelids. 

labels for atopic keratoconjunctivitis

enlarge     the anatomy

Atopic keratoconjunctivitis diagram

enlarge      the problems

The condition causes inflammation of the surface of the eye. The conjunctiva (the skin covering the eye) can develop tiny lumps, limbitis. In addition, the under surface of the upper lid also becomes inflamed. The eye is very red and itchy to start with. When the condition is very active, it is very hard to open the eyes.

If the condition is not treated, the eye becomes very dry, and corneal scarring can reduce the sight. Corneal ulcers can develop, and later also scars. Later and the cornea and the undersurface of the upper lid can become scarred.

The condition can start as a child, young adult or adult, and can continue for many years.

 

Symptoms

 

Vernal keratoconjunctivitis

In this condition the surface of the eye becomes red and sore and inflamed. This is a type of allergic eye disease, and is similar to atopic keratoconjunctivitis and giant papillary conjunctivitis. The immune system becomes overactive; a type 2 hypersensitivity reaction. The cause is not known, but it is partly genetic. There are environmental factors we partly understand, and these are discussed below.

The condition affects the conjunctiva, the cornea, and the conjunctiva under the eyelids. 

labels for atopic keratoconjunctivitis

enlarge     the anatomy

Atopic keratoconjunctivitis diagram

enlarge      some of the problems

The conjunctiva (the skin covering the eye) can develop tiny lumps, limbitis. In addition, and the under surface of the upper lid also becomes inflamed. The eye is very red and itchy to start with. When the condition is very active, it is very hard to open the eyes.

If the condition is not treated, the eye becomes very dry, and corneal scarring can reduce the sight. Corneal ulcers can develop, and later also scars. Later and the cornea and the undersurface of the upper lid can become scarred.

The condition can start as a child, young adult or adult, and can continue for many years.

 

Shield ulcers and giant papillae

shield ulcer...shown by he green circleenlarge

shield ulcers on the cornea (shown in green)

 






giant pailary conjunctivitis

enlarge

Giant papillae under the lid

 

 

 

 

 

 

 

 

VKC or AKC?

Recurrent angioedema

Allergic rhinitis in children: treatment

 

Eczema of eyelids

 

Links

 

Penicillin